Clinical Skills Flashcards
A 25 year old presents to the Emergency Centre with stridor. A possible cause for this sign is: A. Pneumonia B. Croup C. Anaphylaxis D. Asthma
C. Anaphylaxis
A 32 year old male is brought into the emergency unit following a motor vehicle accident. You start examining him and hear gurgling noises. You should first:
A. Call a sister to get the intubating equipment and a doctor to come and intubate him.
B. Suction the secretions in his mouth and administer a jaw thrust to open his airway.
C. Ignore the sounds
D. Get the ambubag and start ventilating him.
B. Suction the secretions in his mouth and administer a jaw thrust to open his airway.
You want to defibrillate a patient with a monophasic machine. The correct Joule setting is: A. 100 J B. 200 J C. 300 J D. 360 J
D. 360 J
You are attending to a 40 year old male patient who has been shot in the abdomen. He is anxious, pale peripherally and his vitals are: Pulse 105, Blood Pressure 100/65, Respiratory Rate 24. He is in A. Class I shock B. Class II shock C. Class III shock D. Class IV shock
B. Class II shock
C. Class III shock
Whilst walking around the Emergency Centre, you notice an unconscious patient. On examination she has dilated pupils. A possible cause for this could be: A. Organophosphate overdose B. Heroin overdose C. Morphine administration D. Atropine administration
D. Atropine administration
You respond to a patient who had called the ambulance because he had chest pain. On arrival you find him unresponsive, not breathing (and so give 2 breaths) and pulseless. He was talking to his wife 1 minute before your arrival. You have an AED (automated external defibrillator) with you. Your actions should be:
A. None of these options are correct
B. Start Cardiopulmonary resuscitation and apply the pads after 2 minutes
C. Call for a doctor to come and apply the pads
D. Apply the pads and follow the directions given
D. Apply the pads and follow the directions given
Options:
- Hands over the lower end of the sternum between the nipples
- Compression rate of 100/min and compression depth of 4-5 cm
- Compression: ventilation ratio of 15:2
- Allow full recoil of the chest between compressions
- Lift your hands off the chest between each compression
The correct technique for chest compressions in an adult includes the following: A. 1,2 and 4 B. 1,2,3 and 4 C. 2,3 and 5 D. 1,3 and 5
A. 1,2 and 4
Options:
- Check and open his airway
- Call the ambulance service for help.
- Check his pulse and do CPR for 2 min if needed
- Check his breathing and gives 2 breaths if needed
You are alone and you find your 2 year old brother collapsed on the floor. You assess for hazards and then assess responsiveness. If he is unresponsive your actions (in order) should be: A. 1,4,3 then 2 B. 1,2,3 then 4 C. 2,1,3 then 4 D. 2,1,4 then 3
A. 1,4,3 then 2
Options:
- Bend over/ crouch
- Approach from the front
- Only approach when told you may by the pilot
- Approach from uphill
- Ensure that you have no loose items on you
When approaching a helicopter you should
A. 1,2,3 and 5 B. 1,3 and 5 C. 1,2,4 and 5 D. 1,3,4 and 5
A. 1,2,3 and 5
In the following case scenario choose the best management option.
A 25 year old presents to the emergency unit after overdosing on Heroin. You assess her and find her unresponsive, with a respiratory rate of 0 and Pulse of 60 palpable at carotids.
A. Supply supplemental Oxygen (Venturi or Facemask Oxygen)
B. Ventilate the patient at a rate of 1 breath every 5 sec
C. Ventilate the patient at a rate of 2 breaths every 30 sec
D. Ventilate the patient at a rate of 2 breaths every 30 compressions
B. Ventilate the patient at a rate of 1 breath every 5 sec
In the following case scenario choose the best management option.
A 16 year old presents to the emergency unit with pneumonia. He is fully awake with a respiratory rate of 32 and saturation of 90%.
A. Supply supplemental Oxygen (Venturi or Facemask Oxygen)
B. Ventilate the patient at a rate of 1 breath every 5 sec
C. Ventilate the patient at a rate of 2 breaths every 30 sec
D. Ventilate the patient at a rate of 2 breaths every 30 compressions
A. Supply supplemental Oxygen (Venturi or Facemask Oxygen)
A 40 year old female is brought in by her relatives. They say she has had “flu” for 3 days. Her vitals are: BP 85/40; Heart rate of 135 bpm and Respiratory rate 34. On examination you find Bronchial breathing in her left lower lobe. She is warm peripherally. A. Cardiogenic shock B. Obstructive shock C. Distributive shock D. Hypovolaemic shock
C. Distributive shock
In the following case scenario what type of shock is present.
A 20 year old male is brought in complaining of severe shortness of breath. He has had asthma since he was 8 years of age. His vitals are: BP 85/40; Heart rate 135 bpm and Respiratory rate 28. On examination you find pulsus paradoxus and very soft wheezing bilaterally (almost a silent chest). A. Cardiogenic shock B. Obstructive shock C. Distributive shock D. Hypovolaemic shock
B. Obstructive shock
In the following case scenario what type of shock is present.
A 30 year old male presents to the Emergency Centre after being stung by a bee. His vitals are: BP 85/40, Heart rate of 125 bpm and Respiratory rate of 30bpm. On examination you find generalised urticaria. A. Cardiogenic shock B. Obstructive shock C. Distributive shock D. Hypovolaemic shock
C. Distributive shock
In the following case scenario choose the correct GCS from the options provided:
You are attending to a patient who has been hit on the head with a spade. He opens his eyes when you talk to him, localises to painful stimulus and responds to your questions by using inappropriate words. 3, 5, 3 A. 7 B. 9 C. 10 D. 11
D. 11
In the following case scenario choose the correct GCS from the options provided:
A 17 year old is brought in after being involved in a motor vehicle accident. He is not responding to voice. You administer supraorbital pressure and in response to that he opens his eyes, groans and flexes his elbow, supinates his forearms and flexes his wrists. 2, 2, 3 A. 7 B. 9 C. 10 D. 11
A. 7
IV Indications
Administration of fluid and nutritional support
Administration of IV medications
Administration of blood products
Administration of contrast agents for investigations (e.g. CT scan)
IV Contraindications
There are no absolute contra-indications
Avoid inserting an IV line in a limb that is infected, injured or burned
Avoid using peripheral IV lines for administering irritant medications which can lead to tissue damage (central lines preferred)
Is IV a sterile procedure?
Yes
IV Complications
Pain Failure to access the vein Difficulty advancing the cannular over the needle Haematoma Arterial puncture Thrombophlebitis Skin and soft tissue infection or necrosis Peripheral nerve palsy (rare)
IM Indications
Patient cannot tolerate oral intake
Medication only comes as intramuscular formulation
Require fast onset of action
Focussed administration of medication to a particular area
IM Contraindications
Allergy or previous reaction to the medication
Local skin infection or skin damage at the injection site
Injury to the muscle at the injection site
What is Ampoule?
An ampule, or ampoule, is a tiny single dosage vial with a sealed neck. Ampoules could be of glass or plastic.
The seal is unfastened by cracking the top off the neck, that causes a tidy and hassle-free break without any additional glass shards or slivers. Ampoules cannot be reused and once the sealed neck is snapped off to have access to the drug, it is thrown away.
What is a Vial?
Vial is a small multi-dose container that can hold serums, liquid drugs and other compounds. It is typically made of glass and may or may not be sealed. Vial, in the form of container possesses a screw on cap or a rubber plug.
IM Sites
Deltoid (1-2ml)
Gluteus: dorsogluteal (5ml)
Gluteus: ventrogluteal (3ml)
IM Complications
Bleeding
Infection e.g. abscess, cellulitis
Adverse reaction to medication (ranging from mild reaction to anaphylaxis)
Injury to other structures e.g. nerves, blood vessels, muscle breakdown
Indications for whole blood
Massive haemorrhage with high risk of recurrence
Established, severe hypovolaemic shock
Blood replacement after burns
Indications for packed red cells
Ongoing haemorrhage following initial volume resuscitation with fluids
Symptomatic anaemia (normovolaemic) when iron therapy is not indicated
Preoperatively for non-elective surgery
Indications for platelet transfusion
Severe thrombocytopaenia (e.g. bone marrow failure) or platelet dysfunction
To prevent bleeding
To treat active bleeding
Indications for fresh frozen plasma
To replace deficient clotting factors e.g. warfarin toxicity, liver cirrhosis
Contraindications for transfusion
Patient refusal
Cardiac conditions with a risk of volume overload: cardiac failure, aortic stenosis
History of adverse reactions to blood products (not an absolute contra-indication)
Transfusion site
Any peripheral vein may be used for the blood transfusion- the antecubital fossa is ideal
Transfusion cannula size
A new cannula should be inserted for the blood transfusion. A larger bore cannula ( 14g, 16g or 18g)should be inserted to avoid haemolysis or clotting
Transfusion products - inpsection
Red cell concentrate: should not be darker than attached segments
Plasma: should not be murky, purple, brown or red
Platelets: cloudy yellow or straw coloured with no visible aggregates
Fresh frozen plasma: clear yellow or straw colour
Cryoprecipitate: cloudy straw colour
Life-threatening transfusion complications
Transfusion-related circulatory overload: pulmonary oedema due to increased circulatory volume from a massive blood transfusion or cardiac failure
Transfusion-related acute lung injury: the activation of neutrophils in the pulmonary vasculature by the blood product. This results in respiratory distress, a fever and chills.
Acute haemolytic transfusion reaction: intravascular haemolysis of transfused RBCs due to ABO incompatibility, rhesus incompatibility or incompatibility to other antigens. Patients usually present with a fever, chills, flank pain and oozing from IV sites.
Transfusion-associated sepsis: transfusion of a blood product that contains a microorganism, resulting in a large intravenous inoculation. Patients may experience a fever, chills and hypotension.
Anaphylactic transfusion reaction: occurs in patients who are allergic to a constituent of the blood product or who are IgA deficient and produce anti-IgA antibodies that react with the IgA in the transfused product. Patients may present with angioedema, bronchospasm and hypotension.
Non-life-threatening transfusion complications
Urticarial transfusion reaction: occurs due to an antigen-antibody reaction between the patient and constituents of the blood product. Patients present with hives or skin changes without bronchospasm, angioedema or hypotension.
Febrile non-haemolytic transfusion reaction: the release of cytokines from a white blood cell containing blood product. Patients present with a fever and chills without any other systemic symptoms. This is a diagnosis of exclusion.
Primary hypotensive reactions: a drop in blood pressure by more than 30mmHg for the duration of the blood transfusion. It is a diagnosis of exclusion and is associated with platelet transfusions or the use of ACE-inhibitors.
Other transfusion complications
Hypothermia Hyperkalaemia Hypocalcaemia Citrate toxicity in massive transfusions Disseminated intravascular coagulopathy Acid base changes
Blood culture indications
Blood cultures are only taken when there is a clinical need to do so and NOT as a routine.
Identify patients with bacteraemia.
Suspicion for an infection of the blood (septicaemia)
Monitoring the effectiveness of antimicrobial therapy of blood-borne infections
Critically ill patients
Intravenous catheters site
infection
Blood culture contraindicationd
Patients with coagulopathy or on blood- thinning agents should be carefully assessed prior to obtaining blood cultures. Determine if the procedure’s benefits outweigh the risks
Skin infection near or at the puncture site
Blood should not be taken from intravenous cannula, unless an infected intravenous line is suspected
Blood should not be taken from the veins that are proximal to an existing peripheral intravenous cannula and should ideally be taken from a different limb
Lymphoedema- obtain blood fron alternative site
Blood culture - preferred vein
The median cubital vein is the preferred vein to use, however any easily accessible vein can be used as long as there are no contraindications
Blood culture complications
Haematoma may develop
Continuous bleeding from site
Localised skin infection may develop
Contamination of blood samples leading to inappropriate use of treatment
Rejection of the specimen by the lab, usually because of haemolysis or because the volume is inadequate
Needlestick injury
ECG Indications
To monitor patient`s heart rate and rhythm
To detect presence of an ischaemia or damage
To evaluate effect of disease on heart function
To obtain a baseline function of the heart before, during and after surgical procedure
LP Indications
Diagnostic
Therapeutic
LP Contraindictions
Absolute
Infection at site of LP
Severe spinal deformities
Patient refusal
Relative Raised ICP Space-occupying lesions in the brain Uncorrected coagulopathies Brain abscess
LP - location
To perform a safe lumbar puncture, the needle is inserted between the L3/L4 or L4/L5 vertebrae.
LP - layers
It passes from the skin - subcutaneous tissue - supraspinous ligament - interspinous ligament - ligamentum flavum - dura mater -arachnoid mater – subarachnoid space.
LP - measuring opening pressure
Patients must be in the left lateral decubitus position
LP Complications
Post-LP headache Haemorrhage or haematoma Infection Lower back pain Radicular pain or numbness Cerebral herniation Epidermoid tumours of the thecal sac (rare)
Nebulisation Indications
To administer medication directly into the airways in patients with certain airway diseases
To treat an acute asthma or COPD exacerbation with a bronchodilator or anticholinergic
To regularly treat severe asthma or a reversible airways obstruction, when those patients have previously benefitted from higher doses of medication
To provide prophylaxis for asthma or COPD in patients who struggle with other devices
To administer an antibiotic to a patient with a chronic purulent chest infection
To administer pentamidine for the prophylaxis and treatment of pneumocystis pneumonia
Nebulisation Contraindciations
Patients with unstable and increased blood pressure
Patients with a tachycardia (nebulisation may still be administered if the benefits outweigh the risks)
Patients with cardiac irritability, which may manifest as an arrhythmia
Unconscious patients (inhalation may be done via a mask, but the therapeutic effect may be significantly low)
Patient refusal
Nebulisation Complications
Palpitations Tremors Tachycardia Headache Nausea Bronchospasms (too much ventilation may exacerbate bronchospasms)
